Persevering in Tough Budget Times

How one county's health department is expanding its reach through efficiency and innovation.

To continue to be able to provide critical public health services in the face of budget cuts of about $15 million, the Multnomah County Health Department had only once choice: to evolve.

Under the leadership of Lillian Shirley, the department has persevered amid severe financial constraints by capitalizing upon technology and staff capabilities and finding new ways to help people before they get sick in the first place.

The department has consolidated responsibilities, trained staff to work in new ways , and created new systems to help prevent costly and debilitating illnesses such as asthma and tuberculosis.

For example, the HIV/Viral Hepatitis Community Program and STD prevention were separate programs; now they’re now merged. STD clinic workers—not RNs—take and screen blood samples. The department discovered this improved patient compliance and allowed its clinic to treat more patients, more quickly.

The Environmental Health Division’s Healthy Homes project now has trained staffers conduct home visits to identify asthma triggers such as dust and roaches, as well as to show patients and their families how to contain the triggers. Over time, this reduces thedisease’s burden and cost.

In part because of this improved efficiency and flexibility, the department was able to respond to the H1N1 outbreak by reassigning available staff and creating new positions to meet the community’s new health care needs.

“The health department is resilient,” says Shirley, Multnomah County’s health director and vice president of the National Association of County and City Health Officials (NACCHO).

The need to become more efficient has required Shirley and her team to make tough decisions. For the current fiscal year 2009-2010, the department’s budget was slashed from $151 million to $136 million, forcing it to cut 50 positions. And Shirley says her budget director recently warned that planning for new cuts could come sooner than expected, as the budget cycle beginning July 1, 2010, may have a shortfall. But she is up to the challenge.

“We have to really think about how we spend those dollars for the public and that’s part of our public trust,” Shirley says. “We’ve demonstrated we can survive and grow no matter how challenging our times.”

Among the health department’s other changes:

Initiatives aimed at addressing health promotion, health equity and health analysis are now part of a single unit.

In the Clinical Services department, everyone works to the full capacity of their training. Since July, certified technicians, rather than nurses, have distributed medications through the department’s prison pharmacy.

Innovations include a new approach to directed observational therapy for tuberculosis. Previously nurses or aides made regular home visits to observe patients taking their medicine and to ensure completion of the regimen. Now, health aides are able to observe patients via a videophone system set up in both the patient’s home and at the public health department offices. As a result department is saving $160,000, says Arlene Warren, R.N., program manager of the county’s Communicable Diseases Services.